What are the recommended hospice comfort‑care medication dosing parameters for a do‑not‑resuscitate (DNR) patient receiving comfort‑care only?

Hospice Comfort Care Medication Parameters for DNR Patients

For DNR patients receiving comfort-care only, use opioids for pain/dyspnea (morphine starting 0.5-1 mg/h IV/SC), benzodiazepines for agitation/anxiety (midazolam 0.5-1 mg/h, titrate to 1-20 mg/h), and antipsychotics for delirium (levomepromazine 12.5-25 mg every 8h or haloperidol), with continuous infusions preferred over bolus dosing to maintain sustained symptom control. 1

Opioids for Pain and Dyspnea

Morphine is the cornerstone medication for pain and respiratory distress in hospice patients 1:

• Starting dose: 0.5-1 mg/h continuous infusion, with 1-5 mg as needed for breakthrough symptoms 1
• Usual effective dose: 1-20 mg/h continuous infusion 1
• Routes: IV or subcutaneous administration 1
• Key principle: Continue pre-existing opioid regimens unless signs of overdose (respiratory suppression) occur; do not rapidly withdraw opioids due to withdrawal risk 1

Critical pitfall: Avoid rapid opioid titration algorithms that can cause opioid toxicity and increased discomfort 2. The evidence shows that aggressive escalation protocols from older order sets lead to worse outcomes 2.

Benzodiazepines for Agitation and Anxiety

Midazolam is first-line for agitation, anxiety, and terminal restlessness 1:

• Starting dose: 0.5-1 mg/h continuous infusion 1
• Breakthrough dosing: 1-5 mg as needed 1
• Usual effective dose: 1-20 mg/h continuous infusion 1
• Advantages: Rapid onset, can be co-administered with morphine or haloperidol, available IV or SC 1
• Adverse effects: Paradoxical agitation (especially in elderly), respiratory depression, withdrawal if rapidly reduced, tolerance development 1

Important distinction: Benzodiazepines can worsen delirium if used as initial treatment for confusion; differentiate anxiety from delirium before administration 1.

Antipsychotics for Delirium

When patients manifest delirium (acute confusional state), antipsychotics are indicated rather than benzodiazepines 1:

Levomepromazine (First-line for delirium)

• Starting dose: 12.5-25 mg, with 50-75 mg continuous infusion option 1
• Usual effective dose: 12.5-25 mg every 8 hours with every 1 hour PRN for breakthrough agitation, or up to 300 mg/day continuous infusion 1, 3
• Advantages: Rapid onset, antipsychotic effect, some analgesic properties, multiple routes (oral, IV, SC, IM) 1
• Adverse effects: Orthostatic hypotension, paradoxical agitation, extrapyramidal symptoms, anticholinergic effects 1

Chlorpromazine (Alternative antipsychotic)

• Starting dose: IV/IM 12.5 mg every 4-12 hours, or 3-5 mg/h IV, or 25-100 mg every 4-12 hours per rectum 1
• Usual effective dose: Parenteral 37.5-150 mg/day, per rectum 75-300 mg/day 1
• Advantages: Widely available, multiple administration routes including rectal 1

Refractory Sedation: Barbiturates and Anesthetic Agents

For patients with extreme tolerance to opioids and benzodiazepines, or refractory symptoms requiring deeper sedation 1:

Phenobarbital

• Loading dose: 1-3 mg/kg SC or IV bolus 1
• Starting infusion: 0.5 mg/kg/h 1
• Usual maintenance: 50-100 mg/h 1
• Advantages: Rapid onset, anticonvulsant properties 1
• Critical note: No analgesic effect; continue opioids for pain 1

Propofol

• Loading dose: 20 mg 1
• Infusion: 50-70 mg/h 1
• Advantages: Very rapid onset, short duration allows easy titration 1

Medication Management Principles

Continue vs. Discontinue

• Continue: All medications providing symptom palliation unless ineffective or causing distressing side effects 1, 3
• Discontinue: Medications inconsistent with or irrelevant to comfort goals (e.g., vasopressors like norepinephrine, antibiotics unless treating symptomatic infections) 3
• Taper gradually: When withdrawing medications like vasopressors, reduce by 25-50% every 30-60 minutes to avoid rebound effects 3

Route Considerations for Home Hospice

For patients at home with swallowing difficulty, non-oral routes are essential 4:

• Sublingual: Morphine, lorazepam tablets, atropine drops 4
• Rectal: Acetaminophen suppositories, chlorpromazine 4, 1
• Subcutaneous: Morphine, midazolam, levomepromazine 1

Research shows 67% of caregivers used comfort care kits at home, with 98% finding them effective and easy to use 4.

Monitoring Parameters

Focus exclusively on comfort, not vital signs 3:

• Monitor for: Respiratory distress, agitation, pain, grimacing 3, 5
• Do not monitor: Blood pressure, heart rate, oxygen saturation unless they inform comfort interventions 3
• Clinical observation: Use clinical judgment rather than structured sedation scales; aim for patients to be "comfortable," "calm," or "relaxed" 5

The median continuous midazolam dose in practice is 10 mg/24h (range 0.4-69.5 mg/24h), demonstrating that clinicians use the lowest effective doses for comfort rather than deep sedation 5.

Common Pitfalls to Avoid

1. Do not use aggressive titration protocols that rapidly escalate opioids, as this causes toxicity 2
2. Do not treat delirium with benzodiazepines first; this worsens confusion 1
3. Do not rapidly withdraw opioids even if overdose signs appear; reduce gradually to avoid withdrawal 1
4. Do not continue vasopressors simply because blood pressure is low; hypotension without symptoms does not cause suffering 3
5. Do not perform routine vital sign monitoring in imminently dying patients; this shifts focus from comfort 3

Practical Dosing Algorithm

Step 1: Assess primary symptom

• Pain/dyspnea → Morphine 0.5-1 mg/h 1
• Agitation/anxiety → Midazolam 0.5-1 mg/h 1
• Delirium → Levomepromazine 12.5-25 mg 1

Step 2: Titrate to comfort (not sedation)

• Increase by 25-50% increments every 30-60 minutes based on symptom response 3, 5
• Use lowest effective dose 5

Step 3: Add adjunctive medications as needed

• Combine morphine + midazolam for pain with agitation 1
• Add antipsychotic if delirium emerges 1

Step 4: For refractory symptoms

• Consider phenobarbital or propofol 1
• Ensure opioids continued for pain 1